Provider Demographics
NPI:1053470617
Name:COFFEE FAMILY MEDICINE
Entity Type:Organization
Organization Name:COFFEE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-384-2353
Mailing Address - Street 1:200 DOCTORS DR
Mailing Address - Street 2:STE 224
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2201
Mailing Address - Country:US
Mailing Address - Phone:912-384-2353
Mailing Address - Fax:
Practice Address - Street 1:200 DOCTORS DR
Practice Address - Street 2:STE 224
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2201
Practice Address - Country:US
Practice Address - Phone:912-384-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6594Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER